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Responding to the Opioid Addiction Epidemic

Responding to the Opioid Addiction Epidemic. Andrew Kolodny, M.D. Chief Medical Officer Phoenix House Foundation New York, NY. The Opium Poppy Papaver Somniferum. Crude Opium Latex on Poppy Head. Opioids. Morphine Codeine Thebaine Diacetylmorphine (Heroin) Hydrocodone ( Vicodin)

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Responding to the Opioid Addiction Epidemic

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  1. Responding to the Opioid Addiction Epidemic Andrew Kolodny, M.D. Chief Medical Officer Phoenix House Foundation New York, NY

  2. The Opium PoppyPapaver Somniferum

  3. Crude Opium Latex on Poppy Head

  4. Opioids • Morphine • Codeine • Thebaine • Diacetylmorphine (Heroin) • Hydrocodone (Vicodin) • Oxycodone (Oxycontin) • Oxymorphone (Opana) • Hydromorphone (Dilaudid) Naturally occurring opioids- also called opiates Semi-synthetic opioids

  5. Prior Opioid Addiction Epidemics • Late 1800s: Morphine • Mainly middle class • Female > Male • Early 1900s: Heroin (pharmaceutical grade) • First generation Italians, Jews, Irish • Male > Female • 1950s-1970s- Heroin (illicit) • African American/Latinos • Male > Female

  6. Governor Shumlindevotes entire state of the state speech to Vermont’s opioid addiction epidemic

  7. Unintentional Drug Overdose Deaths United States, 1970–2007 38,329 drug overdose deaths in 2010 Cocaine Heroin Year National Vital Statistics System, http://wonder.cdc.gov

  8. Drug Overdose Deaths by Major Drug Type,United States, 1999–2010 CDC, National Center for Health Statistics, National Vital Statistics System, CDC Wonder. Updated with 2010 mortality data.

  9. Primary non-heroin opiates/synthetics admission rates, by State (per 100,000 population aged 12 and over)

  10. Primary non-heroin opiates/synthetics admission rates, by State (per 100,000 population aged 12 and over)

  11. Primary non-heroin opiates/synthetics admission rates, by State (per 100,000 population aged 12 and over)

  12. Primary non-heroin opiates/synthetics admission rates, by State (per 100,000 population aged 12 and over)

  13. Primary non-heroin opiates/synthetics admission rates, by State (per 100,000 population aged 12 and over)

  14. Primary non-heroin opiates/synthetics admission rates, by State (per 100,000 population aged 12 and over)

  15. Non-heroin opioid admissions, by gender, age, race/ethnicity: 2011

  16. Heroin admissions, by age group & race/ethnicity: 2001- 2011

  17. Unintentional overdose deaths involving opioid analgesics parallel per capita sales of opioid analgesics in morphine equivalents by year, U.S., 1997-2007 * Number of Deaths Opioid sales (mg/person) Source: National Vital Statistics System, multiple cause of death dataset, and DEA ARCOS * 2007 opioid sales figure is preliminary.

  18. Rates of Opioid Sales, OD Deaths, and Treatment, 1999–2010 CDC. MMWR 2011

  19. Dollars Spent Marketing OxyContin (1996-2001) Source: United States General Accounting Office: Dec. 2003, “OxyContin Abuse and Diversion and Efforts to Address the Problem.”

  20. Industry-funded “education” emphasizes: • Opioid addiction is rare in pain patients. • Physicians are needlessly allowing patients to suffer because of “opiophobia.” • Opioids are safe and effective for chronic pain. • Opioid therapy can be easily discontinued.

  21. Industry-funded organizations campaigned for greater use of opioids • Pain Patient Groups • Professional Societies • The Joint Commission • The Federation of State Medical Boards

  22. “The risk of addiction is much less than 1%” Porter J, Jick H. Addiction rare in patients treated with narcotics. N Engl J Med. 1980 Jan 10;302(2):123 Cited 824 times (Google Scholar)

  23. N Engl J Med. 1980 Jan 10;302(2):123.

  24. “I think that after 20 years of a failed experiment that there are not many people supporting this except for the die-hards and the pharmaceutical industry.” Jane C. Ballantyne, MD FRCA Professor, Univ. of Washington Source: New York Times, April 9, 2012. “Tightening the Lid on Pain Prescriptions”.

  25. The Emperor’s New Paradigm: Patient Selection, Risk Stratification & Monitoring

  26. Urine Tox Results in Chronic Pain Patients on Opioid Therapy Source: Couto JE, Goldfarb NI, Leider HL, Romney MC, Sharma S. High rates of inappropriate drug use in the chronic pain population. Popul Health Manag. 2009;12(4):185–190.

  27. Controlling the epidemic:A Three-pronged Approach • Prevent new cases of opioid addiction. • Treatment forpeople who are already addicted • Supply control- Medical board & law enforcement efforts to reduce over-prescribing and black-market availability.

  28. Opioid manufacturers continue to advertise opioids as safe and effective for chronic pain.

  29. How the opioid industry Frames the Problem Source: Slide presented by Lynn R. Webster MD at FDA meeting on hydrocodone upscheduling, January 25th, 2013.

  30. Drug overdose death rates by intent by age group, US, 2008

  31. This is a false dichotomy Aberrant drug use behaviors are common in pain patients 63% admitted to using opioids for purposes other than pain1 Pain Patients “Drug Abusers” 35% met DSM V criteria for addiction2 92% of opioid OD decedents were prescribed opioids for chronic pain. 1. Fleming MF, Balousek SL, Klessig CL, Mundt MP, Brown DD. Substance Use Disorders in a Primary Care Sample Receiving Daily Opioid Therapy. J Pain 2007;8:573-582. 2. Boscarino JA, Rukstalis MR, Hoffman SN, et al. Prevalence of prescription opioid-use disorder among chronic pain patients: comparison of the DSM-5 vs. DSM-4 diagnostic criteria. J Addict Dis. 2011;30:185-194. 3. Johnson EM, Lanier WA, Merrill RM, et al. Unintentional Prescription Opioid-Related Overdose Deaths: Description of Decedents by Next of Kin or Best Contact, Utah, 2008-2009. J Gen Intern Med. 2012 Oct 16.

  32. Frequently Discussed Interventions • Abuse-deterrent formulations • Expanding access to naloxone • Expanding access to medication assisted treatment • PDMP-based interventions • Mandatory prescriber education

  33. Buprenorphine Treatment • Partial agonist • Weaker effects • Safer to use • Long duration of action • Milder withdrawal symptoms

  34. Full Opioid Agonists

  35. Buprenorphine- A Partial Agonist

  36. Summary • We are in the midst of the worst drug epidemic in U.S. history. • To end the epidemic we need to: • PREVENT new cases of opioid addiction • TREAT people who are already addicted

  37. www.supportPROP.org Please visit @andrewkolodny

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